Navigating Managed Medicaid

We know that finding a therapist near you in or near Garden City NY of Long Island who takes your Managed Medicaid plan with Fidelis Healthfirst or Community Plan is important in your care and we are happy to be able to provide services under these plans.

​Managed Medicaid Plans Accepted:   Fidelis, HealthFirst, UHC Community Plan

​The following is general information to best of our knowledge about obtaining Managed Medicaid plans but please be to sure to take into account all your benefits and circumstances and consult with others to see if this is best for you.

Navigating Managed Medicaid

Have you had a significant life change that has or may impact your insurance? If so one of these may apply to you:

Scenario 1:

At times when you apply through the state or another entity for other types of benefits, the office of Medicaid or another entity may by default change your insurance back to straight Medicaid. This can happen during renewals, when states try to streamline services, or when your other benefits or income changes. This can happen because Medicaid programs must coordinate benefits with other entities and also because the choice of a more specific plan is yours to make. The challenge is that this default change to straight Medicaid can limit your provider network and access to specialized care, which are typically managed through a Managed Medicaid plan. In order to see a provider here see help getting Managed Medicaid.

Scenario 2:

If you have had a recent change of income, may no longer be eligible to be on another's insurance plan, or have another qualifying life event, you may be eligible for a Medicaid managed care or essential insurance plan. If so, you could receive full or significant coverage for therapy visits here if selecting a plan we are in network with. In order to see a provider here see help getting Managed Medicaid.

Scenario 3:

You never had Managed Medicaid and were automatically assigned NY Medicaid or Straight Medicaid. This may not be an error, but as mental health providers under our provider type we are only able to accept Managed Medicaid Plans which in the simplest of terms means that a specific insurance company would be managing a portion of you Medicaid benefits and access to certain care and providers such as us. Read on for help with getting a Managed Medicaid Plan we accept.

Help obtaining Managed Medicaid

It is best to call the number through the NYS health exchange (1.855.355.5777) and let them know you believe you may qualify for a Medicaid level or Essential plan or already have Medicaid but want to choose a managed Medicaid plan. These plans are not always viewable on the main website. 

The Medicaid plans we accept are Healthfirst, UHC Community, and Fidelis.

Here is the link to the New State of Health website to look into enrolling and questions you might have: https://info.nystateofhealth.ny.gov

You may want to consider the following when changing your insurance:

-Make sure any necessary medical treatment you need such as providers, medications would be covered under the new plan. Our clients thus far have not had issues when switching but every situation is unique.

-Discuss any impact on co-insured family members if applicable

-Ask if there would be any deductible or copay for 'routine professional individual mental health visits'. Medicaid and Essential plans usually are $0 to $15 but higher level essential plans may be more or have a deductible.

-If you have insurance through your job and are considering opting out of that and getting a plan through the exchange, make sure to examine compare the effects of this.

-The NYS of health assigns insurance agents to help clients navigate benefits and you can view full benefit descriptions online before choosing.

Thank you and we hope this is of help.

Navigating Insurance Deductibles, Copays and Coinsurances

 Health insurance terms can be confusing and overwhelming for clients and providers alike. Here we try our best to explain some basics.

What is a deductible?

​For mental health coverage, a deductible (if it applies) is the amount you pay out-of-pocket for covered services before your insurance company starts to share the cost. Once you meet your deductible for the plan year, you will likely only owe a copayment, coinsurance, or percentage for future sessions.

Mental health deductible:

The annual cost you pay first: The deductible is a set dollar amount that you are responsible for paying each year before your insurance starts to assist. For example, if your plan has a $1,500 deductible and a $30 copay, you will pay 100% of your mental health care costs until you've paid $1500 for the year and before your insurance covers part of the cost. 

This does NOT mean that for a session/one service you pay $1200. It means that you pay the full contracted amount for the service each session ($80 for example) until you have met the deductible for the plan year. Additionally if you attend 4 sessions and pay $320 towards them and then stop therapy, you would NOT need to pay further towards the deductible as it applies to USE of services.

Example: 

In-network therapist's contracted fee: $80 per session

Deductible: $1200

Copay: $30

You would pay $80 per session for 15 sessions ($1200) and then the cost would be reduced to $30 per session for the remainder of the year.

Deductibles reset annually: Your deductible resets at the start of each plan year. This means you will need to meet it again when the plan year renews before your insurance begins to cover costs again.

After meeting your deductible: Once you've paid the full deductible amount, your insurance will begin to cover a portion of your therapy costs. At this point, you will likely transition to paying only a copayment or coinsurance (the example of $30).

*Does not include premiums: The deductible is different from your monthly insurance premium. Your premium is the fixed amount you pay to your insurance plan, regardless of whether you use any services.

What are copays and coinsurances?

This pertains to the amount you pay aside from any deductible that may or may not apply. 

Copayment: A fixed dollar amount you pay for each session ($30)

Coinsurance: A percentage of the cost you pay for each session (10% so for example $10 percent of $80 would be $8.00).

While most insurance plans have EITHER a copay OR deductible it is possible for them to apply both and depends on your plan.

Another example:

In-network therapist's contracted fee: $80 per session 

Annual deductible: $1200

Coinsurance: 20% ($16)

Here’s how your costs would be calculated:

First 15 sessions ($80 x 15 = $1200): You would pay the full $80 for each session. By the 16th session and for the rest of the plan year your 20% coinsurance kicks in. So, for the remainder of the year you pay $16.

Some plans either do not have deductible at all or the deductible does not apply to mental health services. When you start therapy here we get a quote from your insurance regarding deductible and copay/coinsurance and if your deductible applies.

 

Thank you and we hope this is of help.

Interview with The Huffington Post: Sibling Relationships

Question & Answer with Michelle Ambalu, Lcsw

Featured in The Huff Post:  The Unbreakable Bond...

What importance does the role of a sibling play in a "broken" home?

During times of significant changes within or disruptions to the family dynamic, a sibling can often take on the role of the primary attachment figure during childhood particularly in regard to providing attunement and allowing for safe exploration as well as regulation at a time when the typical primary caregiver is less able to offer this; there are many stressors or changes that can lead to a temporary or enduring unavailability including but not limited to illness, time served, death, divorce, work, depression, substance abuse, etc. 

In regard to a chaotic home environment siblings may care after one another though often children may take on polarized roles that can appear confusing or misleading. Many times one child in the family becomes what is called the 'identified patient"; this child is the one that is exhibiting symptoms viewed as problematic by others. Often that child is showing us the disturbance that is being disowned (typically unconsciously) by the entire family to allow for the illusion of or some level of functioning; the child absorbs the disturbance which manifests in behavioral issues or symptoms. 

 It is important to focus on the triggers leading to chaos rather than who is to blame. When a tornado rips through your town, you are the ones left with the signs of distress and all the pieces to pick up even though the tornado caused this; If we view family disturbance (tatters and chaos) as created by the tornado (trigger) for a moment, it is easier to do so. That family needs help processing the trauma, adjusting to the change, and obtaining the tools and resources to do so. When a family is unable to do this it is akin to them pretending/going through the motions as if the walls and furniture are still there (denial) or rigidly holding onto the idea that this is the way they are supposed to live often coming up with rationalizations. So when one child finally breaks these defenses either verbally or through manifested behaviors, the parent(s) become anxious and the other children follow suit in their defense. 

With siblings there is a chance (provided that other factors are leading to this resilience) that siblings come together to try and break the defense. With a sibling there is the opportunity for reality checking and reassurance with one another similar to an employee having coworkers to debrief with regarding their employment or bosses.

How does age difference affect sibling bond or interdependence?

When a sibling is much older than another I often observe that the older sibling can become like a second parent to the younger sibling, or the younger sibling can be seen as a much greater threat given the developmental difference and time that has passed without the younger sibling. The longer something stays the same, and the older we get, the harder it can be to adjust to a major change. Sometimes the vast age difference leads to estrangement.

What role does teasing play in the development of sibling bonds?

Playful teasing allows for a healthy expression of fondness and a bit of aggression all in one and to see the impact we have on one another; it allows us to play with boundaries and is often a rite of passage on the way to belonging to a group which is why siblings can help us develop other peer relationships. Teasing can also be a good way to remedy or normalize a slightly clumsy social interaction. If the aggressive/competitive component is taken too far with teasing this can of course lead to difficulties with other peers as well.

Is sibling rivalry important to sibling relationship and social development? Or is it a detriment?

I think it can go both ways but healthy rivalries can transfer to non-domestic relationships in learning how to compete for what we want and cope with defeat or slights.

Is it arguable that a relationship between siblings is more important than the relationship between parent and child? (in a non-abusive, relatively healthy, home environment). 

Research lags far behind in regard to the importance of siblings as compared to parents and the importance is underestimated.

Do you think children with siblings are at any sort of developmental advantage over only children?

Early on it has been observed that a child can learn to do a new task faster when another child a bit older teaches them as opposed to an adult; this can be attributed to the motivation of the play bond as well as the unique communication.

What areas of a person's development and/or identity do siblings impact the most (perhaps more than anyone else in a person's life)?

Siblings can teach you things that parents cannot. Parents focus on rules/appropriateness while sibling will help with social norms/unspoken rules through modeling. A child who has no siblings/cousins as well as limited social activity with peers is often understandably bewildered as to why he/she had a social blunder and furthermore does not have a peer on hand to process it which would have helped them make some helpful changes or to shrug it off. It is just as important to have a peer give you some tips as it is for them to normalize what happened simply by saying something to the effect of “Yeah… been there, done that… I remember when that happened to me, it was really hard - but tomorrow it will blow over or they'll move on to something else”. It usually helps whether it is ‘true’ or not.

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